The nurse prepares to administer a continuous intravenous infusion through a peripheral IV to a client who has dehydration. Which is the priority nursing assessment before initiating the IV infusion?

1. A

   Checking a daily body weight

2. B

   Checking the serum electrolyte

3. C

   Checking intake and output records

4. D

   Asking the client about the dominant side

Appeared in: DHS 2018 shift 1st

Explanation

• The priority assessment immediately before the physical procedure of IV insertion is selecting an appropriate site.
• Asking about the dominant side is a critical step in site selection to preserve the client's ability to perform activities of daily living (ADLs).
• Using the non-dominant arm enhances patient comfort and cooperation and is considered a standard of care.
• While other assessments are important for the overall plan of care, site selection is the most immediate task before cannulation.

Why Other Options Were Wrong

• Option A: Checking daily body weight is the best way to monitor fluid status changes over time and evaluate the effectiveness of therapy, not the priority action immediately before the procedure of inserting the IV.
• Option B: While checking electrolytes is vital for ensuring the correct type of IV fluid is administered, it is part of the broader assessment and planning phase, not the immediate procedural step of site selection.
• Option C: Reviewing intake and output records helps in assessing fluid balance trends but is less accurate than daily weight and is not the immediate priority before the physical act of IV insertion.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Priority nursing assessment for peripheral IV insertion in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Prioritizing the non-dominant arm for IV placement is a fundamental aspect of patient-centered care that directly impacts the patient's comfort and functional independence during their hospital stay.
• Failure to consider hand dominance can lead to patient frustration and may increase the risk of IV dislodgement if the catheter is in a frequently used hand.
• What if? If the client were unconscious or unable to communicate, the nurse would assess both arms for suitability, looking for clues of dominance (e.g., more developed musculature) or simply choosing the arm in better condition, while still aiming to preserve function.

How to Approach the Question

• First, identify the core task in the question: 'initiating a continuous intravenous infusion through a peripheral IV'.
• Next, pinpoint the key qualifier: 'priority nursing assessment before initiating'. This directs you to the most immediate and critical action just before the physical procedure.
• Evaluate each option in the context of the nursing process (Assessment, Diagnosis, Planning, Implementation, Evaluation).
• Differentiate between assessments for overall planning and evaluation (weight, labs, I&O) and the specific assessment required for the immediate implementation of the task (site selection).
• Recognize that asking about the dominant side is a primary step in site selection, which is the first part of the implementation phase.
• Conclude that the action most directly tied to the immediate procedure, promoting patient comfort and function, is the priority.

Concept Tested & Keywords

• Concept Tested: Priority nursing assessment for peripheral IV insertion
• Stem keywords: priority nursing assessment, before initiating, peripheral IV, dehydration
• Lead-in keywords: priority

Question ID

QWoeMnOBRigY5jvqvV855B

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 82-84

E6 Pharmacology Nursing Lilley 11e Part 2 p. 168-170